The Importance of Physician and Medical Coder Communication By Rachel M. Mitchell, CPC-H Interaction between a physician and medical coder is a significant aspect of medical claims processing. It is important that both parties exhibit a mutual respect for each other’s skills and expertise. A coder should be comfortable advising a physician on medical documentation or requesting clarification on a service that he or she performed. At the same time, a physician must be willing to accept this advice. Proper documentation leads to increased reimbursement while incorrect or inadequate documentation will lower reimbursement and possibly raise compliance issues. It is the coder’s responsibility to make sure that the practice compliance is not at risk and that the rules and regulations are communicated to all members of the practice. Periodic documentation auditing is essential to maintaining optimal reimbursement. The coder should initiate a retraining session with the physician every six months. These meetings are necessary to ensure that the clinical staff has been made aware of any serious documentation trends that may lead to inadequate reimbursement. Such trends would include repetitively making statements such as “all systems are negative” rather than listing the body systems separately, or billing for services that are not considered medically necessary. Effective communication between the physician and coder can help prevent many problems related to billing Auditing is one of the seven OIG compliance elements and medical practices should therefore set goals based on accuracy. Ninety-five percent is considered to be an acceptable accuracy level, though many practices will aim for a higher level. If a documentation audit indicates that accuracy is falling below the acceptable level, it is necessary for the staff to determine which mistakes are being made and work together to find a solution. Retraining sessions should be given at this time and periodic audits should be scheduled to follow up on any changes that are made.. Another important aspect of medical documentation is the continuing education for the coding and billing staff. Coding and billing rules and regulations constantly change and your practice must change with them to remain compliant. To do this, your office personnel must stay informed and receive up-to-date training and education. This education can be obtained through on-site training, seminars, and other various methods. Though this training may seem expensive the benefits generally outweigh the costs. Physicians should not view spending on continuing education as an additional debt but as a worthwhile investment that will lead to increased revenue in the long run. There are also several organizations that offer seminars and online training at no charge, including Medicare and Medicaid. To access Medicare’s online information please visit www.medicaretraining.com. If a limited staff is a consideration when deciding whether or not to send employees to seminars, there are online and audio classes available. Several organizations that offer online education for medical coding and billing are: www.ahimacampus.org, www.ama-assn.org, and www.medicode.com. In addition to online material, St. Anthony’s publishing, Medicode, and The Coding Institute offer many publications and reference materials to assist with continuing education. Ms. Mitchell is the Billing and Coding Manager for Applied Medical Systems, Inc., an accounts receivable management company in Durham, North Carolina. Ms. Mitchell has over 10 years experience in medical billing, coding and consulting. For any questions regarding the above editorial you may reach Ms.Mitchell at (919) 477-5152 or at [email protected] This article is reprinted with permission from the February 2002 issue of M.D. News magazine.